Provider Demographics
NPI:1386644631
Name:WAICKMAN, MICHAEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:WAICKMAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:544 WHITE POND DR
Mailing Address - Street 2:SUITE B
Mailing Address - City:AKRON
Mailing Address - State:OH
Mailing Address - Zip Code:44320-1141
Mailing Address - Country:US
Mailing Address - Phone:330-867-3767
Mailing Address - Fax:330-867-4857
Practice Address - Street 1:544 WHITE POND DR
Practice Address - Street 2:SUITE B
Practice Address - City:AKRON
Practice Address - State:OH
Practice Address - Zip Code:44320-1141
Practice Address - Country:US
Practice Address - Phone:330-867-3767
Practice Address - Fax:330-867-4857
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-07-28
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-05-9865-W174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2197475Medicaid
OHB78258Medicare UPIN
OHWA067431Medicare ID - Type UnspecifiedMEDICARE GROUP NUMBER